The Issue Whether Petitioner made a timely election to participate in the Florida Flexible Benefits Plan (Plan) in accordance with Rule 60P-8.0041(2), Florida Administrative Code and if not, should his participation in the Florida Flexible Benefits Plan (the Plan) for the Plan Year of December 1, 1991, through December 31, 1992, be denied. Whether Petitioner would be entitled to reimbursement from the Plan for medical expenses incurred prior to November 12, 1992, provided it is determined that Petitioner made a timely election to participate in the Plan in accordance with Rule 60P-8.0041(2), Florida Administrative Code.
Findings Of Fact Upon consideration of the oral and documentary evidence adduced at the hearing, the following relevant findings of fact are made: At all times material to this proceeding, the Petitioner was a full- time employee of the University of Florida, Institute of Food and Agriculture Science (IFAS) in Hardee County, Florida and as such, was eligible to participate in the Plan Medical Reimbursement Account provided he timely elected to participate and was otherwise qualified. The Respondent is the state agency charged with the responsibility of administering all state insurance plans for state employees in the State of Florida. As part of its insurance program, the State of Florida offers the Florida Flexible Benefits Plan. The Plan is a benefit program for state employees under which specified, incurred medical expense may be reimbursed. The period of coverage for the Plan material to this proceeding was December 1, 1991 through December 31, 1992. Petitioner did not enroll in the Plan during the open enrollment period for all state employees conducted by the Division during the month of October 1991. During the summer of 1992, and again in October 1992, (sometime after the child was born on October 5, 1992) the Petitioner's wife, Karen S. Weaver, contacted the Division by telephone to inquire about, and to get clarification on, enrolling in the Plan based on a "Change In Family Status" (the child' birth) after the effective date of the Plan, December 1, 1991. On both occasions, Karen Weaver talked with an enrollment agent of the Division and, other than the child's date of birth, no effective date was discussed. The enrollment agent advised Karen Weaver that the Petitioner could not apply until after the birth of the child due to the documentation needed concerning the child's birth. Neither Karen Weaver nor Petitioner were ever advised that with proper certification of pregnancy from the wife's doctor that Petitioner could apply before the birth of the child. After the wife's last conversation with the Division, the Petitioner completed and signed a Reimbursement Account Enrollment/Qualifying Status Change Form, Form FB-2 (the Form) which was dated October 23, 1992. Whether the Petitioner returned the Form to IFAS's personnel office by mail or hand delivery is not clear from the record. However, a notation on the bottom of the Form indicates the Form was received by the personnel office of IFAS on November 9, 1993. The Form was received by the Division on November 12, 1992. The instructions in the Revised September 1991 Florida Flexible Benefits Plan booklet on when Form FB-2 must be submitted provides in pertinent part as follows: Requests must be made by submitting a completed Enrollment/Qualifying Status Change Form, FB-2 (available from your personnel office), to DSEI within 31 days of the event's occurrence. . . . The instructions on the reverse side of Form FB-2 as to the submission of the form provides: Return this completed from to your personnel office. It must be received at DSEI within 31 days of your employment or change in family/employment status. The personnel office is responsible for sending the form immediately upon its receipt to DSEI. THE EFFECTIVE DATE OF PLAN PARTICIPATION OR CHANGE IN FAMILY/EMPLOYMENT STATUS WILL BE THE DATE THE SIGNED AND PROPERLY COMPLETED FORM AND DOCUMENTATION ARE RECEIVED BY DSEI. Petitioner was accepted in the Plan with an effective date of enrollment being November 12, 1992, the date the Division received the Form from Petitioner. The Petitioner elected to contribute $900.00 to the Plan Medical Reimbursement Account to fund reimbursement payment for incurred medical expenses. The Petitioner's acceptance in the Plan was based on the Division having: (a) considered the child's birth as a qualifying status change and; (b) determined that the Petitioner had timely elected to participate in Plan in accordance with Rule 60P-8.0041(2), Florida Administrative Code, in that the Form has been completed and dated (not received by the Division) within 31 calendar days of the occurrence of the qualifying status change. There was insufficient evidence to establish facts to show that within 31 calendar days of occurrence (child's birth) of Qualifying Status Change the Petitioner had: (a) placed the Form with the U.S. mail or similar carrier for delivery to the personnel office of IFAS for submission to the Division; (b) placed the Form with the U.S. mail or similar carrier for submission with the Division; (c) hand delivered the Form to the personnel office of IFAS for submission to the Division or; (d) hand delivered the Form to the Division. Notwithstanding that the notation on the bottom of the Form indicates that the personnel office of IFAS had the Form in its possession as early as November 9, 1992, there is competent substantial evidence to show that the Division did not receive the Form until November 12, 1992. Likewise, there is competent substantial evidence to show that the Respondent did not make a timely election to participate in the Plan by submitting the Form to the Division within 31 calendar days of occurrence (child's birth) of qualifying status change as required by Rule 60P-8.0041(2), Florida Administrative Code, notwithstanding that the Form was dated October 23, 1992, well within the first 31 calendar days of occurrence (child's birth) of the qualifying status change. On December 14, 1992, the Petitioner submitted a claim for medical expense reimbursement for his wife and infant daughter for medical expenses incurred in the month of March, April, June, October and December, 1992. By letter dated December 24, 1992, the Division advised the Petitioner that expenses incurred prior to his enrollment date of November 12, 1992, (the date the Form was received by the Division) were not eligible for reimbursement and to resubmit claims for services incurred after November 12, 1992. There was no evidence presented as to whether the Petitioner resubmitted the medical expenses incurred during the month of December 1992, for reimbursement. The Petitioner contends that the Division should grant Petitioner an exception to the requirement that the effective date must be the date Form FB-2 is received by the Division and allow the effective date in this instance to be the date of occurrence, October 5, 1992, (date of child's birth) of qualifying status change. The Petitioner's contention is based primarily on the fact that the verbal instructions from the Division was misleading, and that the Division had made an exception by allowing the Petitioner to participate in the Plan even though the Petitioner had not timely elected to participate in the Plan in accordance with Rule 60P-8.0042, Florida Administrative Code. The Division denied the Petitioner's request for an exception contending that there is no provision for granting an exception in either case. The Division also contends that date Form FB-2 is completed and signed is the date to be used to in calculating the 31-calendar day requirement to determine if an employee has timely elected to participate in the Plan in accordance with Rule 60P-8.0041(2), Florida Administrative Code. The Division's position is expressly stated in Petitioner's exhibit 8 wherein William H. Lindner, Secretary, Department of Management Services, is responding to a letter from Petitioner and states: In your letter you indicated that an exception had been made in the enrollment process. It had not. Subsection 60P- 8.0041(2), F. A. C. (copy enclosed) indicates that an election to participate in the reimbursement accounts must be made within the first 31 calendar days of the occurrence of the Qualifying Status Change. Our records indicate that you made your election on October 23, 1992 which is within 31 days of the birth of your child on October 5, 1992. The records indicate that the Form was signed on October 23, 1992, well within the 31-day requirement but was not received by the Division until November 12, 1992, some seven days after the 31-day requirement had expired.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law, it is recommended that the Respondent, Department of Management Services, Division of State Employees' Insurance enter a final order finding that the Petitioner failed to timely elect to participate in the in Plan in accordance with Rule 60P-8.0041(2), Florida Administrative Code, was not qualified to participate in the Plan, and any participation in the Plan allowed by the Division was void ab initio. It is further recommended that the Division refund all contributions made by the Petitioner to the Plan after adjustment for any reimbursement for medical expenses that may have been made to the Petitioner by the Division. DONE AND ENTERED this 16th day of February, 1994, in Tallahassee, Florida. WILLIAM R. CAVE Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 16th day of February, 1994. APPENDIX TO RECOMMENDED ORDER NO. 93-5571 The following constitutes my specific rulings, pursuant Section 120.59(2), Florida Statutes, on all of the Proposed Findings of Fact submitted by the parties in this case. Petitioner, Gregory E. Weaver's Proposed Findings of Fact. The following proposed finding(s) of fact are adopted in substance as modified in the Recommended Order. The number in parenthesis is the Finding(s) of Fact which so adopts the proposed finding(s) of fact:1(1); 3-4(5); 5-6(9); 7(6,11); 9(11); 10(6,11); 11(9,16); 12(9); 13(8); 14-15(13); 16(15); 17(16); 18(5) and 19(6). Proposed Finding of Fact 2 is neither material nor relevant to this proceeding. Proposed Finding of Fact 8 is more properly covered in the Conclusions of Law. Proposed Finding of Fact 20 is more an argument than a finding of fact. Respondent's Proposed Findings of Fact. The following proposed findings of fact are adopted in substance as modified in the Recommended Order. The number in parenthesis is the Finding(s) of Fact which so adopts the proposed finding(s) of fact: 1(1,2); 2(3); 3(4,6,9); 4(9); 7(13); and 8(14). Proposed finding of fact 5 is not supported by competent substantial evidence in the record. See Findings of Fact 10 and 11. Proposed finding of fact 6 is adopted in substance as modified in Findings of Fact 6 and 11, except for the first sentence which is rejected as I find no evidence as to the Form being mailed. Proposed findings of fact 9 and 11 ( there is no proposed finding of fact 10) are adopted in substance as modified in Finding of Fact 7 and 8. COPIES FURNISHED: Gregory Weaver Route 1, Box 423 Wauchula, Florida 33873 Augustus D. Aikens, Esquire Division of State Employment Insurance 2002 Old St. Augustine Road, B-12 Tallahassee, Florida 32301-4876 William H. Lindner, Secretary Department of Management Services Knight Building, Suite 307 2737 Centerview Drive Tallahassee, Florida 32399-0950 Alecia Runyon, Director Division of State Employees Insurance 2002 Old St. Augustine Road, B-12 Tallahassee, Florida 32301-4876 Paul A. Rowell, General Counsel Department of Management Services Knight Building, Suite 307 2737 Centerview Drive Tallahassee, Florida 32399-0950
The Issue Whether the State of Florida Employees Group Health Self Insurance Plan is responsible for paying medical expenses incurred by Petitioner's newborn child where Petitioner had only individual coverage in effect at the time of the child's birth.
Findings Of Fact The State of Florida makes available to its employees several group insurance programs. In the area of health insurance, employees may choose to participate in the State of Florida Employees Group Health Self Insurance Plan (State Group Plan), or they may enroll in other plans, such as HMOs. The State Group Plan is a plan of self insurance established by the State and administered by Blue Cross/Blue Shield. This plan is described in general terms by a Plan Brochure and is described in more detail by the contract of insurance contained in the State Self Insured Health Plan's Benefit Document (Plan Document). The State Group Plan is regulated by those rules contained in Chapter 22K, Florida Administrative Code. At the time employees begin their employment with the State, they may select which, if any, of the optional health insurance programs offered by the State they desire. Thereafter, employees may only join one of the insurance programs or switch between programs during an annual open enrollment period. An employee who elects coverage from the State Group Plan may purchase either individual coverage or family coverage. Individual coverage provides health insurance coverage for only the individual employee. Family coverage provides health insurance coverage for the individual employee and the employee's eligible dependents for whom the employee has elected coverage. Family coverage does not begin until after the application for coverage is processed and the premium for family coverage is paid. The monthly premium for family coverage is paid one month in advance. An employee can, but he does not have to, wait for an open enrollment period to switch from individual coverage to family coverage. An employee having individual coverage may change to family coverage at any time during the year prior to the acquisition of an eligible dependent or at a time that is within 31 days of the date of acquisition of any eligible dependent. If family coverage is requested after the acquisition of the dependent, there is a gap in the coverage of the dependent between the date of acquisition and the date coverage begins. There is no retroactive coverage. An employee who completes the pertinent application for family coverage, who submits the application, and who pays the first month's premium for family coverage prior to the acquisition of the dependent has family coverage in place at the time the dependent is acquired through birth, adoption, or other means. Consequently, there is no gap in coverage between the date of acquisition and the effective date of coverage for that dependent. Petitioner is an associate professor of management and Director of the Doctoral Studies Program in the College of Business Administration at Florida International University (FIU). Petitioner teaches courses in a variety of areas including business administration, wage and salary administration, and insurance benefits. Petitioner enrolled in the State Group Plan in 1982. Petitioner was knowledgeable about the State Group Plan and had, from time to time, compared its benefits to those of other plans. At the time of their marriage, Petitioner and his wife reviewed their insurance coverage and decided not to convert their individual policies to one policy with family coverage. From the date of his initial enrollment until April 1989, Petitioner had individual coverage. On March 8, 1989, Petitioner executed the forms that were necessary to change his individual coverage to family coverage. Petitioner's family coverage went into effect on April 1, 1989, after the application was processed and the premium was collected. In March 1988 Petitioner married Annette Wellinghoff. Petitioner and his wife retained their respective individual insurance policies after their marriage. Mrs. Kroeck was not a state employee so the insurance coverage she had was independent of her husband's coverage. In August 1988 Petitioner and his wife learned that Mrs. Kroeck was pregnant with an expectant due date in February 1989. In August 1988, Petitioner telephoned the personnel office at FIU to inquire as to obtaining coverage for the expected child. The general information given Petitioner in response to his questions was accurate. He was told that he could convert his individual coverage to family coverage, if he so desired, during the open enrollment period scheduled for December 1, 1988, through January 31, 1989. There was no evidence that Petitioner specifically inquired as to when he should begin family coverage in order to have the child's birth expenses covered. Likewise, there was no evidence that Petitioner was specifically told that he could convert his coverage to family coverage after the birth of his child and have the medical expenses covered from the time of birth. Petitioner did not request any written information about the conversion process, nor did he request an application form to effectuate the conversion. Petitioner did not know the name of the person with whom he was speaking, only that she was a representative of the personnel office. Petitioner did not contact the FIU Personnel Office again until after the birth of his son. Instead, Petitioner relied upon his wife to take care of securing health insurance. Petitioner delegated this responsibility to his wife because she was also experienced and knowledgeable in matters concerning employee benefits and health insurance plans. Mrs. Kroeck has had at least 3 years experience in health insurance benefits administration. In December 1988 general information relating to the open enrollment program was mailed to all state employees, including Petitioner. Included in the information package were a Plan Brochure for the State Group Plan and an enrollment form for the various insurance options offered to State employees. Mrs. Kroeck read the application form and a portion of the Plan Brochure. Neither Petitioner nor his wife read, prior to the birth of their child, the section of the Plan Brochure entitled "Purpose of This Brochure". That section states that the Plan Brochure is not intended to be a contract document, that it is intended to give a summary of available benefits, and that an employee should contact either his personnel office or the office of the Division of State Employees' Insurance for the answer to questions. The employee is told that the contract document is the Plan Document and that a copy of the Plan Document is on file at the employee's personnel office. That section also contains the following admonition: The agency personnel office will provide needed assistance to State officers and employees enrolling in the Plan; however, such officers or employees should take care to assure that they receive the coverage applied for and that proper deductions are made. On January 9, 1989, Mrs. Kroeck telephoned the personnel office at FIU with questions relating to listing the unborn child as a dependent on the application form that had been mailed to Petitioner in December. Her questioning centered on how to complete the name, date of birth and social security number for an unborn dependent. Clara Martinez, the employee in the personnel office to whom Mrs. Kroeck spoke, does not recall talking to Mrs. Kroeck on January 8, 1989. At the time of this conversation, Ms. Martinez knew that family coverage had to be in place prior to the acquisition of a dependent for the dependent to be covered as of the date of acquisition. If Ms. Kroeck had asked Ms. Martinez a question to which Ms. Martinez did not know the answer, Ms. Martinez would have contacted the office of the Division of State Employees Insurance in Tallahassee for the answer. The evidence fails to establish that Mrs. Kroeck was misinformed by Ms. Martinez or that she specifically inquired as to the effective date of the family coverage. On February 19, 1989, Mrs. Kroeck had her baby. The baby was admitted to the hospital in his own name and incurred, in his own name, expenses in the amount of $4,274.95, for which Petitioner and his wife were responsible. On March 8, 1989, Petitioner signed an application to change his individual coverage to family coverage. Family coverage became effective on April 1, 1989, after the application was processed and the premium for family coverage was collected. At the time of the birth of his son, Petitioner had individual coverage issued through the State Group Plan. Petitioner's son was not a beneficiary under the State Group Plan at the time the medical expenses which are at issue were incurred. Petitioner's request for payment of the medical expenses incurred by his son at birth was denied by Respondent and this proceeding followed.
Recommendation Based on the foregoing findings of fact and conclusions of law, it is RECOMMENDED that Respondent, Department of Administration enter a final order which denies the claim for payment of the medical expenses incurred by Petitioner's son prior to the effective date of family coverage. DONE AND ENTERED this , 27th day of December, 1989, in Tallahassee, Leon County, Florida. CLAUDE B. ARRINGTON Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 27th day of December, 1989. APPENDIX TO RECOMMENDED ORDER, CASE NO. 89-4929 The following rulings are made on the proposed findings of fact submitted on behalf of Respondent. 1. The proposed findings of fact in paragraph 1 are adopted in material part by paragraph 7 of the Recommended Order. 2. The proposed findings of fact in paragraph 2 are adopted in material part by paragraph 7 of the Recommended Order. 3. The proposed findings of fact in paragraph 3 are adopted in material part by paragraph 8 of the Recommended Order. 4. The proposed findings of fact in paragraph 4 are adopted in material part by paragraph 9 of the Recommended Order. 5. The proposed findings of fact in paragraph 5 are adopted in material part by paragraph 9 of the Recommended Order. 6. The proposed findings of fact in paragraph 6 are adopted in material part by paragraph 9 of the Recommended Order. 7. The proposed findings of fact in paragraph 7 are adopted in material part by paragraph 11 of the Recommended Order. The proposed findings of fact in paragraph 8 are adopted in material part by paragraph 13 of the Recommended Order. The proposed findings of fact in paragraph 9 are rejected as being subordinate to the findings made. The proposed findings of fact in paragraph 10 are adopted in material part by paragraph 12 of the Recommended Order. The proposed findings of fact in paragraph 11 are rejected as being unnecessary to the conclusions reached. The proposed findings of fact in paragraph 12 are adopted in material part by paragraph 12 of the Recommended Order. The proposed findings of fact in paragraph 13 are rejected as being unnecessary to the conclusions reached. The proposed findings of fact in paragraph 14 are adopted in material part by paragraph 10 of the Recommended Order. The proposed findings of fact in paragraph 15 are rejected as being unnecessary to the conclusions reached. The proposed findings of fact in paragraph 16 are rejected as being unnecessary to the conclusions reached. The proposed findings of fact in paragraph 17 are rejected as being unnecessary to the conclusions reached. The proposed findings of fact in paragraph 18 are rejected as being unsubstantiated by the evidence as to Ms. Alam and as being unnecessary to the conclusions reached as to Ms. Martinez. The proposed findings of fact in paragraph 19 are rejected as being subordinate to the findings made. The proposed findings of fact in paragraph 20 are rejected as being unnecessary to the conclusions reached. The proposed findings of fact in paragraph 21 are adopted in material part by paragraph 13 of the Recommended Order. The proposed findings of fact in paragraph 22 are rejected as being unnecessary to the conclusions reached. The proposed findings of fact in paragraph 23 are adopted in material part by paragraph 8 of the Recommended Order. The proposed findings of fact in paragraph 24 are adopted in material part by paragraph 18 of the Recommended Order. The proposed findings of fact in paragraph 25 are adopted in material part by paragraph 16 of the Recommended Order. The proposed findings of fact in paragraph 26 are adopted in material part by paragraph 5 of the Recommended Order. The proposed findings of fact in paragraph 27 are adopted in material part by paragraph 4 of the Recommended Order. COPIES FURNISHED: Augustus Aikens, Jr., Esquire Department of Administration 435 Carlton Building Tallahassee, Florida 32399-1550 Kark G. Kroeck 9853 Costa del Sol Boulevard Miami, Florida 33178 Alette A. Lhutes, Secretary Department of Administration 435 Carlton Building Tallahassee, Florida 32399-1550 William A. Grieder, Esquire Office of the General Counsel Department of Administration 435 Carlton Building Tallahassee, Florida 32399-1550
The Issue The issue for consideration herein is whether the Petitioner is entitled to reimbursement from the Florida Flexible Benefits Plan Medical Reimbursement Account for expenses incurred prior to March 8, 1990.
Findings Of Fact At all times pertinent to the matters in issue here, the Petitioner, Quintin A. Clark, was a full-time employee of the Department of Health and Rehabilitative Services in its Sarasota County Public Health unit, and the Respondent, Department, was the state agency responsible for administering all state insurance plans for state employees in the State of Florida. As a part of its insurance program, the state offered the Florida Flexible Benefits Plan, (Plan). This is a benefit program for employees under which specified, incurred medical expenses may be reimbursed. The plan extends for the fiscal year December 1 to November 30 of each year. There is a reimbursement maximum of $2400.00 per year and the maximum reimbursement may not be substantially in excess of the total premium paid for the participant's coverage. During the month of October, 1989, the Respondent conducted an open enrollment period of all state employees who wished to enroll in the plan. Petitioner did not enroll during that open enrollment period. However, in February, 1990, after the birth of his daughter on January 11, 1990, he elected to enroll in the plan and was accepted on the basis that the birth of his child was considered a qualifying status change event. Mr. Clark elected to contribute $1,650.00 per year in the Medical Care account to fund reimbursement payment for medical expenses, and authorized deductions of $82.50 per paycheck for 20 biweekly pay periods. By the same token, he also elected to contribute $1,700.00 to the Dependent care account for dependent care reimbursement and authorized a payroll deduction for that expense of $85.00 per biweekly payroll cycle. Mr. Clark submitted his Form FB-2, Enrollment/Qualifying Status Change Form, on February 6, 1990. A copy of that form, revised in December, 1989, reflects, on the back of the employee's pink copy: The effective date of plan participation or qualifying status change will be the date the signed and properly completed form is received by DSEI. The form signed by Mr. Clark does not indicate it is a copy of the revised form, but there is no evidence to indicate the forms are different in this particular. Notwithstanding Mr. Clark submitted his completed form on February 6, 1990, the form was not received by Respondent, DSEI, until March 8, 1990. No explanation was given for the delay of approximately 32 days between the time the form was submitted by Petitioner and the day it reached the Department. On April 24, 1990, Mr. Clark submitted claims for medical reimbursement for his wife and infant daughter for services incurred on the following dates: 6/89 - 1/90. prenatal $130.00 11/6/89 pregnancy 30.00 11/13/89 " 30.00 11/20/89 " 30.00 12/16/89 Hosp. visit 20.30 1/10/90 Sara. Mem. 466.25 1/11/90 Epidural 112.00 1/12/90 Sara. Mem. 789.95 1/12 - 13/90 well baby care 39.00 1/26/90 " " " 37.00 3/9/90 " " " 3.70 Among these claims, the total value of which exceeded $1,386.20, were included claims for services rendered prior to the date DSEI received Petitioner's enrollment form on March 8, 1990. All these claims incurred prior to that date were denied by the Respondent for that reason. Only the March 9, 1990 claim was considered as qualifying and eligible for payment. Petitioner claims that the information contained in the literature on the program given out by the Department is unclear and contradictory. Specifically he refers to the sample instructions which are outlined on Page 17 of the September, 1989 edition of the plan brochure made available to prospective participants. In that portion entitled "Instructions & Information", which appears to be the reverse of the sample form found on Page 16, at 5, the form reads: Expenses must occur within the plan year and while the employee was a plan participant to qualify. The plan year runs from December 1 through November 30. That provision does not appear to be inconsistent with the Department's denial of reimbursement for the expenses claimed prior to March 8, 1990.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is, therefore: RECOMMENDED that a Final Order be entered denying Petitioner, Quintin A. Clark, reimbursement for the expenses incurred prior to February 6, 1990. RECOMMENDED this 13th Tallahassee, Florida. day of November, 1990, in ARNOLD H. POLLOCK, Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 13th day of November, 1990. APPENDIX TO RECOMMENDED ORDER IN CASE NO. 90-4345 The following constitutes my specific rulings pursuant to Section 120.59(2), Florida Statutes, on all of the Proposed Findings of Fact submitted by the parties to this case. FOR THE PETITIONER: 1. Accepted and incorporated herein except that Petitioner was a participant in the plan at the time the expenses were incurred. FOR THE RESPONDENT: 1 - 9. Accepted and incorporated herein. COPIES FURNISHED: Quintin A. Clark 1025 Putnam Drive Sarasota, Florida 34234 Augustus D. Aikens, Jr., Esquire General Counsel Department of Administration 435 Carlton Building Tallahassee, Florida 32399- 1550 Aletta Shutes Secretary Department of Administration 435 Carlton Building Tallahassee, Florida 32399-1550
The Issue The issue in the case is whether David Bumgarner (Respondent) should be assessed a penalty for an alleged failure to obtain workers' compensation coverage for his employees.
Findings Of Fact The Petitioner is the state agency designated to enforce the provisions of Chapter 440, Florida Statutes (2008),1 which requires that employers in Florida obtain workers' compensation coverage for their employees. The Respondent is a sole proprietor based in North Carolina and doing business as "Builders and Assemblers." On February 25, 2009, Ira Bender, an investigator employed by the Petitioner, observed ten men assembling the iron-and-steel frame for a single story storage building being constructed at 7253 Gasparilla Road, Port Charlotte, Florida. The Respondent was present at the time Mr. Bender observed the workers, and Mr. Bender asked the Respondent about the project. The Respondent advised Mr. Bender that he was the owner of the company constructing the building, that the ten men erecting the building frame were his employees, and that they were being paid $10.00 per hour. Mr. Bender, accompanied by the Respondent, then spoke to each of the ten men at the work site and obtained their names and other relevant information. The Respondent provided to Mr. Bender a copy of a certificate of insurance from "Acord" bearing policy number BNUWC0108275. Mr. Bender reviewed the Petitioner's "Coverage and Compliance Automated System" (CCAS) database and information contained on the National Council on Compensation Insurance ("NCCI") website. Both sources are routinely used to monitor and review workers' compensation coverage. Neither the CCAS database nor the NCCI website indicated that the Respondent had workers' compensation coverage valid within Florida for any of the ten employees at the work site or that the Respondent had a valid exemption from coverage for any employee. After discussing the collected information with his supervisor, Mr. Bender issued a Stop Work Order and Order of Penalty Assessment dated February 25, 2009. The Respondent subsequently provided a copy of his workers' compensation policy to the Petitioner. The policy information page attached to the policy is an NCCI-issued form identified as "WC 00 00 01 A." The Respondent's policy's information page provides, in relevant part, as follows: 3.A. Workers Compensation Insurance: Part One of the policy applied to the Workers Compensation Law of the states listed here: NC * * * C. Other States Insurance: Part Three of the policy applies to the states, if any listed here: All states and U.S. territories except North Dakota, Ohio, Washington, Wyoming, Puerto Rico, and the U.S. Virgin islands, and states designated in Item 3.A. of the Information Page. Administrative rules adopted by the Petitioner and referenced elsewhere herein explicitly state that the coverage identified in the Respondent's policy information page is not valid within the State of Florida. Mr. Bender also issued a Request for Production of Business Records on February 25, 2009. Other than the previously referenced insurance certificate and policy, no further business records were provided to the Petitioner by the Respondent. Mr. Bender subsequently forwarded the case to Lynn Murcia, the Petitioner's penalty calculator. Because the Respondent failed to provide business records sufficient to enable computation of a penalty, Ms. Murcia computed the penalty based on an imputed payroll as provided by Florida law. The NCCI publishes the "SCOPES Manual," which contains a commonly-used system of occupational classifications used to determine workers' compensation requirements. In Florida, the SCOPES Manual has been adopted by incorporation into the Florida Administrative Code. The SCOPES Manual identifies the erection of steel or iron frames for buildings not in excess of two stories under classification code 5059. The Respondent's employees were engaged in such activities, and Ms. Murcia therefore properly classified the Respondent's employees under code 5059. Ms. Murcia utilized the SCOPES classification in determining the imputed payroll applicable to this case and, thereafter, computed the penalty according to a worksheet that has been adopted as an administrative rule by the Petitioner. The worksheet is routinely used to calculate penalties applicable to employers who fail to obtain workers' compensation coverage for employees. Based on Ms. Murcia's calculations, the penalty was identified as $1,764,643.98, as was set forth in an Amended Order of Penalty Assessment issued on March 31, 2009. Ms. Murcia's calculation of the applicable penalty, including her reliance on the applicable SCOPES classification codes and the imputation of the Respondent's payroll, was not disputed at the hearing. Her testimony has been fully credited.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that the Petitioner enter a final order assessing a penalty of $1,764,643.98 against the Respondent. DONE AND ENTERED this 9th day of September, 2009, in Tallahassee, Leon County, Florida. S WILLIAM F. QUATTLEBAUM Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 9th day of September, 2009.
The Issue The ultimate issue is whether Julie E. Reeber, Alexander Reeber and Christine Tadry are entitled to receive survivor benefits payable under the Florida Retirement System (FRS) for Marjorie A. McCollum, deceased, under the facts and circumstances of the Case. The factual issue is whether Marjorie A. McCollum was incompetent when she made the designation of beneficiary and under the undue influence of her daughter Suzanne L. Benson.
Findings Of Fact In August of 1991, Ms. Marjorie A. McCollum, a member of the Florida Retirement System (FRS) applied for disability retirement benefits. (Deposition of Stanley Colvin). As part of her application for disability retirement benefits on Form FR-13 (Florida Retirement System Application for Disability Retirement), Ms. McCollum designated her daughter, Suzanne L. Benson, as her beneficiary. (Exhibit 1 of the deposition of Stanley Colvin). The designation reads, "All previous beneficiary designations are null and void. The beneficiary whom I designate to receive the benefit or refund at my death is Suzanne L. Benson." (Deposition of Stanley Colvin, Exhibit 1). According to the date on the form, Ms. McCollum signed the application on August 28, 1991, and was properly witnesses by a notary public, John T. West. (Testimony of Mary Shere). According to the application, Ms. McCollum was suffering from cancer. She selected the Option 2 retirement benefit. (Exhibit 1 of Stanley Colvin deposition). Ms. McCollum's application for disability retirement benefits, with the Option 2 retirement benefit, was approved by the Division of Retirement with an effective date of September 1, 1991. (Deposition of Stanley Colvin, Exhibit 9). Prior to receiving her first check, Ms. Marjorie McCollum died on September 23, 1991. (Deposition of Stanley Colvin, Exhibit 9). On November 4, 1991, the Division, by letter, notified Suzanne L. Benson that as designated beneficiary of Ms. Marjorie McCollum, she was entitled to the Option 2 benefit in the amount of $280.69 per month through August 31, 2001, for ten years. On November 19, 1991, the Division received a letter from Julia Reeber, another daughter of Ms. McCollum (the deceased), disputing the designation of her sister Suzanne L. Benson as the beneficiary. (Deposition of Stanley Colvin, Exhibit 16). As a result of the notice of dispute by Julia Reeber, the Division on November 26, 1991, notified Ms. Benson by letter that payment of the Option 2 benefit would not be forthcoming until the dispute was resolved. (Deposition of Stanley Colvin, Exhibit 12). The designation of beneficiary executed by Ms. McCollum was properly executed and filed with the Division of Retirement in accord with the Florida Statutes and rules pertaining to the designation of beneficiaries for Florida retirement benefits. (Deposition of Stanley Colvin). Suzanne L. Benson was the properly designated beneficiary, and the Division intended to pay the Option 2 benefit to Suzanne L. Benson in accord with the Division's rules. (Deposition of Stanley Colvin). Ms. McCollum suffered some deterioration of her mental faculties prior to her death because of her illness, she could no longer handle her financial matters, and needed aid from her children in the payment of her bills. However, at no time was the Petitioner legally declared incompetent. Testimony of Julie Reeber). Despite suffering from the ravages of the disease, Ms. McCollum was at times able to function in a normal matter without evidence of diminished mental capacity. (Testimony of Mary Shere). On August 23, 1991, the deceased came to the office of Ms. Mary Shere. Ms. McCollum had been a regular customer of Ms. Shere's beauty parlor and later her accounting service. Ms. Shere had known Ms. McCollum for over ten years. (Testimony of Mary Shere). On August 23, 1991, Ms. McCollum and Ms. Shere talked for an hour to an hour and a half regarding her illness and her application for disability retirement. Ms. McCollum expressed her desire for Ms. Shere to notarize the application for disability retirement benefits. Ms. McCollum told Ms. Shere that Ms. McCollum wanted her daughter Suzanne to be the beneficiary of her death benefits. However, they could not complete the designation of beneficiary because the form had not come. Another discussion concerning the arrival of the forms took place by telephone on August 24, 1991, between Ms. Shere and the Deceased. On August 26, 1991, Suzanne Benson telephoned Ms. Shere advising Ms. Shere that her mother had been hospitalized, and that she needed to come to the hospital in order to notarize the disability application. (Testimony of Mary Shere). On August 26, 1991, Ms. Shere accompanied by one of her employees, John West, visited Ms. McCollum in the hospital. In her presence, the application was signed by Ms. McCollum and notarized by John West. (Testimony of Mary Shere). Ms. Shere's very credible testimony was that Ms. McCollum knew what she was doing, was aware of what she possessed and knew she was terminal. Ms. McCollum made a knowing and rational decision to designate Suzanne L. Benson as her beneficiary.
Recommendation Based upon the foregoing Findings of Fact and Conclusions of Law set forth herein, it is, RECOMMENDED: That a Final Order be entered by the Division holding that Marjorie McCollum retired with an Option 2 retirement benefit and that Suzanne L. Benson, her designated beneficiary, receive the Option 2 benefit. DONE and ENTERED this 29 day of May, 1992, in Tallahassee, Florida. STEPHEN F. DEAN, Hearing Officer Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, FL 32399-1550 (904) 488-9675 Filed with the Clerk of the Division of Administrative Hearings this 29 day of May, 1992. COPIES FURNISHED: Julie E. Reeber 133 Kirkwood Drive Debary, FL 32713 Larry D. Scott, Esquire Department of Administration Cedars Executive Center, Building C 2639 North Monroe Street Tallahassee, FL 32399-1560 Rhonda B. Goodson, Esquire Post Office Box 4319 South Daytona, FL 32121 A. J. McMullian, III, Director Division of Retirement Cedars Executive Center, Building C 2539 North Monroe Street Tallahassee, FL 32399-1550 John A. Pieno, Secretary Department of Administration 415 Carlton Building Tallahassee, FL 32399-1550
The Issue Whether at the time of his father's death, Armando Martinez, Jr., was a "dependent beneficiary" of his father, a vested member of the Florida Retirement System, so as to be entitled to his father's retirement benefits?
Findings Of Fact Armando Martinez, Jr., was born on February 22, 1974, to Natalie M. Martinez and the late Armando Martinez, Sr. In 1992, when Armando, Jr., was eighteen years old, Mr. and Mrs. Martinez were divorced. The following year, 1993, less than two weeks after Armando, Jr.'s, nineteenth birthday, Armando Martinez, Sr., died. The cause of death was liver cancer, a disease from which Ms. Martinez presently suffers. At the time of his death on March 7, 1993, Mr. Martinez was a vested member of the Florida Retirement System. A municipal employee, he had been a bus operator. At some point close to commencement of his employment, slightly more than ten years prior to his death, Armando Martinez, Sr., had executed a Form M-10. The form named his wife, Natalie, as his primary beneficiary. Armando, Jr., the only child of Armando, Sr., and Natalie Martinez, was named as the sole contingency beneficiary. Following Mr. Martinez, Sr.'s death, Ms. Martinez disclaimed Florida Retirement System benefits. She did so in order for Armando, Jr., as the contingent beneficiary, to be able to receive the benefits. On February 17, 1997, the Division of Retirement denied Armando, Jr., survivor benefits. Had Mr. Martinez, Sr., died one-year and several weeks earlier, that is, prior to Armando, Jr.'s eighteenth birthday, the Division would have approved distribution of survivor benefits to him. But, although he was still a high school student, since he was older than nineteen by a few days at the time of his father's death, the Division required proof that Armando, Jr., had received half of his support from his father at the time of his father's death. No such proof was provided to the Division prior to or at the time of its preliminary denial. In fact, in his 1992 tax return, Mr. Martinez did not claim his son Armando, Jr., as a dependent. In this formal administrative proceeding, however, Armando Martinez, Jr., provided such proof, proof which was lacking until hearing. The year 1992 was very difficult for Armando Martinez, Jr., and his family. His parents separated, Armando, Jr., lived with his mother. Armando, Sr., lived elsewhere. Prior to his death, divorce proceedings were finalized. In the meantime, Ms. Martinez had lost her job. She remained unemployed for the entire year and in early 1993 as well. Armando, Jr., was still in high school at the time of his father's death. During the 1992-93 school year, to support himself and his mother, he obtained work part-time while he remained in school. Ms. Martinez paid the rent for their apartment at a rate of between $370 and $500 per month. The monthly phone bill of Ms. Martinez and Armando, Jr., was approximately $50; utility payments $70; groceries $300; gasoline $10, automobile insurance $100; and school supplies $40. There were other expenses, clothes, for example, that occurred from time-to-time. In addition to minimal government support to Ms. Martinez and Armando, Jr.'s, part-time employment income, Armando, Jr., was supported by cash payments provided by his father. Two or three times a month, Armando's father and a girl friend, Karen Jones, would drive to the front of the house. Because of his illness, Mr. Martinez remained in the car while Ms. Jones brought cash, usually between two and five hundred dollars in an envelope to the front door. On more than one of these occasions, Ms. Jones, the envelope, and the cash were observed by friends of the family at the moment of delivery. Ms. Martinez log of the estimates of these payments totals approximately $8,500, an amount in excess of Mr. Martinez's income reported in his 1992 tax return filed before his death in 1993 to be $6,389.00. But, Mr. Martinez, Sr. had access to other means of support and other monies including proceeds from insurance policies. The $8,500 provided to Armando, Jr., by Armando Martinez, Sr. constituted more than half of Armando, Jr.'s, support for the year 1992 and up until Mr. Martinez, Sr.'s, death in early 1993.
Recommendation Accordingly, it is hereby recommended that the Division of Retirement recognize Armando Martinez, Jr., to have been the dependent beneficiary of Armando Martinez, Sr., at the time of Mr. Martinez, Sr.'s, death, and therefore entitled to retirement benefits. DONE AND ORDERED this 27th day of January, 1998, in Tallahassee, Leon County, Florida. DAVID M. MALONEY Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 Filed with the Clerk of the Division of Administrative Hearings this 27th day of January, 1998. COPIES FURNISHED: Robert B. Button, Esquire Division of Retirement Department of Management Services Cedars Executive Center, Building C 2639 North Monroe Street Tallahassee, Florida 32399-1560 Natalie Martinez Suite 3811 3801 Northgreen Avenue Tampa, Florida 33624 Paul A. Rowell, General Counsel Department of Management Services 4050 Esplanade Way Tallahassee, Florida 32399-0950 A.J. McMullian, III, Director Division of Retirement Department of Management Services Cedars Executive Center, Building C 2639 North Monroe Street Tallahassee, Florida 32399-1560
The Issue Whether Petitioner is entitled to participate in the Deferred Retirement Option Program (DROP) of the Florida Retirement System (FRS), for the period September 1, 1998, through and including September 30, 1999.
Findings Of Fact Petitioner is a former employee of the School Board of Miami-Dade County (School Board) and is a retired member of FRS. In September 1998, Petitioner became eligible to participate in DROP by virtue of reaching 30 years of service with the School Board. In September 1998, Petitioner asked Respondent for an estimate of her retirement benefits. In January 1999, the estimate of Petitioner's retirement benefits was prepared by Respondent and mailed to Petitioner. During the 1998-99 school year, Petitioner had difficulties in her dealings with a new school principal. 1/ Petitioner testified that she delayed applying for DROP because she believed that her relationship with her employer would improve and she could continue to work as a teacher. Petitioner also testified that School Board administrators gave her erroneous information and misled her as to their intention to permit her to continue to teach. Petitioner argues that she would have elected to participate in DROP beginning September 1, 1998, had her employer told her the truth about her employment status. In this proceeding, Petitioner argues that she be permitted to participate in DROP effective September 1, 1998, on equitable grounds, without specifying the equitable principles upon which she relies. On October 27, 1999, Petitioner completed her application to participate in DROP and filed the application with the School Board's personnel office. Respondent received the completed application via facsimile on November 3, 1999. The first application sent in by Petitioner requested that her DROP participation start retroactive to September 1, 1998. Respondent, through its staff, denied that request and informed Petitioner that she would have to submit a second application, referred to by staff as a corrected application, requesting a start date of October 1, 1999. Pursuant to those instructions, Petitioner submitted a second application requesting that her start date be October 1, 1999. Petitioner's challenge to Respondent's denial of her request to accept her participation in DROP retroactive to September 1, 1998, was timely. Petitioner was later terminated from her position with the School Board. 2/ Respondent has been paid her drop benefits for the period beginning October 1, 1999, and ending when the School Board terminated her employment. Petitioner has not been employed by a FRS employer since the School Board terminated her employment.
Recommendation Based on the foregoing Findings of Fact and Conclusions of Law, it is RECOMMENDED that Respondent enter a final order denying Petitioner's request for benefits under DROP for the period September 1, 1998 to September 30, 1999. DONE AND ENTERED this 10th day of August, 2001, in Tallahassee, Leon County, Florida. CLAUDE B. ARRINGTON Administrative Law Judge Division of Administrative Hearings The DeSoto Building 1230 Apalachee Parkway Tallahassee, Florida 32399-3060 (850) 488-9675 SUNCOM 278-9675 Fax Filing (850) 921-6847 www.doah.state.fl.us Filed with the Clerk of the Division of Administrative Hearings this 10th day of August, 2001
